Don’t Get Too Comfortable With That Meaningful Use Payment – Here’s Why

Tue, Jun 20, 2017

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MU overpayment news

When the title of an OIG report is about Medicare paying out hundreds of millions it shouldn’t have, that’s not great news for Medicare or the providers who got those funds. But that’s exactly what a report released June 12, 2017, says: “Medicare Paid Hundreds of Millions in Electronic Health Record Incentive Payments That Did Not Comply With Federal Requirements.”

Short version: From May 2011 to June 2014, the OIG estimates CMS paid about $729.4 million in EHR incentive payments to eligible professionals (EPs) who didn’t meet meaningful use requirements. A big part of the problem was that EPs didn’t maintain support for their attestations about meeting program requirements, and CMS didn’t do a lot of documentation reviews to catch this problem earlier, according to the OIG. OIG’s recommendations to CMS include attempting recovery of that $729.4 million.

Let’s dig in to the OIG recommendations and CMS’s responses a little more.

1. Get Back the Money From Improper Payments

Several of the OIG recommendations in the report are about recovering the money paid to providers who didn’t meet meaningful use requirements:

  • Recover $291,222 in payments made to EPs included in the OIG’s sample group who didn’t meet meaningful use requirements
  • Review incentive payments made during the audit period to attempt recovery of the estimated $729,424,395 in inappropriate incentive payments
  • Check a random sample of EP documentation from after the audit period to see if there were more inappropriate payments.

CMS agreed with the first point, but only partially concurred with the second two, claiming it already has implemented targeted risk-based audits to strengthen program integrity. The OIG report states those audits aren’t sufficient to catch the errors it found.

2. Educate EPs on Proper Documentation

Because finding appropriate support for attestations was such an issue in the review, the OIG made this recommendation:

  • Educate EPs on proper documentation requirements.

CMS concurred, agreeing to look into whether more education is needed, but pointed out they do have education available, including a fact sheet.

3. Get Back the Money From Overpayments

The OIG reviewed all payments to EPs who switched between the Medicare and Medicaid incentive payment programs and discovered overpayments, resulting in this recommendation:

  • Recover $2,344,680 in overpayments made to EPs who switched programs.

CMS agreed, asking the OIG to share the EPs’ information.

4. Use Edits to Ensure Switch Doesn’t Lead to Overpayments

To ensure providers don’t receive payment for both Medicare and Medicaid incentive programs when the EP switches, OIG had this recommendation:

  • Employ edits in the National Level Repository (NLR) system to guarantee providers who switch programs during the year get payment for only one EHR program.

CMS concurred, indicating it had already implemented the edits.

Bonus Recommendation: Keep Up the Safeguards for MACRA

One of the changes MACRA brings essentially moves the Medicare EHR incentive program into the Merit-Based Incentive Payment System (MIPS) as Advancing Care Information. So the OIG report includes a note that CMS has got to keep pushing to verify reporting of required measures.

What About You?

Do you participate? Have documentation tips to share?

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ICD-10-CM 2018 Posted! Let the Update Games Begin

Fri, Jun 16, 2017

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2018 codes are coming

ICD-10-CM 2018 files are up on the CMS site! Here’s a quick overview of what’s coming when the new version goes into effect Oct. 1, 2017. (Looking for PCS? Click here.)

Check Changes by the Numbers

Based on the files posted, it looks like we’ll be dealing with more than 700 updates:

  • 360 additions
  • 142 deletions
  • 226 revisions
  • 71,704 codes total.

Single Our Your Specialty

Here are some changes from the chapters that will see the most updates. Be sure to check the complete files to see the details on the changes that will affect your specialty.

Eye and adnexa: Some of the changes in this section are as simple as a spelling correction (in H02.05-, entropian becomes entropion). But plenty of updates will have a real impact on your coding:

  • H44.2- (Degenerative myopia) will get new options to identify cases with choroidal neovascularization, macular hole, retinal detachment, foveoschisis, and other maculopathy by eye.
  • H54.- (Blindness and low vision) will see a lot of changes to allow you to identify the category for each eye, such as H54.1131 (Blindness right eye category 3, low vision left eye category 1).

Cardiology and vascular: There are four main areas to watch for these updates:

  • Myocardial infarction codes will expand, including a new specific option for type 2 (I21.A1).
  • Pulmonary hypertension options will increase under I27.2- to allow you to better define cause.
  • Heart failure coding options will grow with about 10 new changes, like I50.813 (Acute on chronic right heart failure) and I50.84 (End stage heart failure).
  • Cerebral infarction (I63.-), embolism and thrombosis (I82.81-), and varicose veins (I83.8-) will get some of those tough-to-spot changes, like revising plural terms to singular, so review those with care if you code them.

Gastroenterology: Coding for intestinal adhesions and obstruction will get more specific with about a dozen additions. To code correctly you’ll need to know whether obstructions are partial or complete.

Wound care: If you thought the non-pressure chronic ulcer code list couldn’t get any longer, think again! You’ll get lots of new options to help you report cases without evidence of necrosis.

Ob-gyn: If you code for women’s health, keep an eye on these changes:

  • You’ll be able to specify quadrant when coding for an unspecified lump in the breast under N63.
  • Tubal (O00.1-) and ovarian (O00.2-) pregnancy codes will expand to let you identify the side affected.
  • New subcategory O36.83- will allow you to report maternal care for abnormalities of the fetal heart rate or rhythm, specific to the trimester and fetus involved.
  • Antenatal screening encounter codes (Z36) will get a makeover with 17 new codes so you can identify what the screening is for, such as nuchal translucency (Z36.82) and Strep B (Z36.84).

Neuro: The list of changes for brain conditions is relatively long, but grasping the updates is pretty simple if you know the breakdown.

  • Injury codes of the optic tract (S04.03-) and visual cortex (S04.04-) will change terminology from “eye” to “side”
  • Expect a mass deletion of subsequent and sequela codes from S06.- that have the phrase “loss of consciousness of any duration with death.” (It makes sense when you think about it.)

Orthopedics: A few minor changes will lead to a whole lot of updates:

  • Code descriptors for metacarpal fracture (S62.3-) have a period in the middle in 2017, so the 2018 version changes that to a comma.
  • Phalanx fracture codes for the finger (S26.6-) and toe (S92.5-) will see a language swap from “medial phalanx” to “middle phalanx.”
  • Subluxation and dislocation codes (S63.12-) for thumb interphalangeal joints will get cleaned up to remove references to proximal and distal.

What About You?

How do you prep for ICD-10-CM updates? Tip: You can get automatic updates by signing up for ICD-10-CM Code Lookup FREE for a year!

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3 Things You Can Do Today to Prepare for a RAC Audit

Wed, Jun 7, 2017

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face audits by being prepared

What’s the first think you think of when you hear Recovery Audit Contractor? RACs have been around for a while (and not without controversy) as part of a Medicare program to find and correct past improper payments. Even folks who don’t get nervous at the thought of an audit probably don’t look forward to the extra work involved and the lengthy appeals process. There are some small steps you can take now to help make that mountain of an audit less intimidating.

1. Monitor Approved RAC Issues

If you haven’t checked your RAC’s approved issues in a while, it’s time to make a date with the contractor’s website. Some experts advise checking for new issues once a month or so.

Example: If you code for a physician in Performant Recovery’s region, you can go to the Approved Issues page and review the issues for your provider type, like payment for a global service along with payment for the service’s professional or technical component. RAC audits look at past claims, but you can still use the approved issue information to self-audit and to inform your training.

2. Pay Attention to LCDS and NCDs

Approved issues often relate to specific LCD and NCD requirements, so you’ll need to look beyond the approved issues page and delve into exactly what the policies say. (Which is just good coding, anyway, right?)

Example:Cotiviti lists Medical Necessity Sacral Neurostimulation as an approved issue. Reviewers check documentation to see whether the service meets coverage criteria, coding guidelines, and medical necessity requirements. The details section for the approved issue lists the specific NCD and LCD policies the review is based on, helping to direct you to the policies you need to know.

Bonus: The more you comply with Medicare rules, the lower your RAC work may be. Here’s why: The RAC program involves Additional Documentation Request (ADR) limits. For instance, a RAC can request only a certain percent of your paid claims in a specified period. The Statement of Work CMS published for RAC regions 1-4 states, “CMS will establish a method to adjust the ADR limits based on a provider’s compliance with Medicare rules.” If your denial rates are low, your ADR limit will be low. If your denial rates are high, then your ADR limit will be high, meaning the RAC can ask for a larger amount of information.

3. Create an Audit Team

Plan now so you don’t have to scramble to meet audit requests later.

For instance: Decide who will be responsible for alerting staff to deadlines, pulling records, and going through documentation before submission. Be sure team members know what they’ll be responsible for so they know what to expect. You also can identify experts from your team and from outside your organization to assist with an audit defense, if needed.

How About You?

Have you been through a RAC audit? What advice do you have for others?

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Step-by-Step Guide to Checking National Correct Coding Initiative Edits on SuperCoder

Tue, Jun 6, 2017

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CCI Edits Checker is one of the tools SuperCoder subscribers use the most, so here’s a quick instructional guide to help users make the most of this resource, including the color-coded results and RVU options.
 
Note: This guide is specific to the CCI Edits Checker for Medicare PTP practitioner edits, but Outpatient Facility Coder subscribers will find that using our OPPS CCI Checker doesn’t vary too much from what you’ll find here.

Step 1: Access CCI Edits Checker

Once you’re logged into an account that includes tools, you can access CCI Edits Checker in several different ways. Start on the Coding Tools page, then choose the path that suits your needs.

1. Coding Tools page: Scroll down the page until you see the CCI Edits Checker widget.

2. Claims Edits page: Click Claims Edits in the top menu. A page with only Claims Edits widgets will open.

3. Dedicated page: Click Claims Edits/CCI Edits Checker in the left-side menu. This will open a new page titled National Correct Coding Initiative (NCCI or CCI) Edits. (Just for fun, which do you say? Medicare NCCI edits or CCI edits?)

Tip: On a code’s details or range page, choose the CCI Edits tab to see if the code is in the Column 1 position in any CCI edit pairs

Step 2: Choose Entry Method

CCI Edits Checker checks up to 25 codes at once. You can choose to enter codes in individual boxes (enter five characters and the cursor jumps automatically to the next box) or in a single box with the codes separated by commas. Click Make It Default, and you won’t have to repeat this step unless you want to change your preference.

Step 3: Choose Version/Date

The Version/Date box is set to the current CCI version based on date of service, but you can check any version going back to 2011.

Step 4: Choose Geographic Locality

Checker results include RVUs and fees for your codes. Select the applicable geographic location to see information specific to that area. Click Make It Default to check that area each time.

Step 5: Choose Setting

Select Non-Facility or Facility to see MPFS RVU/fee information for that setting. Again, you have the option of clicking Make It Default.

Step 6: Enter Codes

Pop in your codes, and click CCI Check.

Step 7: Review Results

The CCI Edits Checker lists your codes in simple descending RVU order based on MPFS data. Next to each code, you’ll see the descriptor and a color-coded alert identifying whether the code is in the Column 2 position in an edit with any of your other codes. Green means you’re in the clear, yellow means there’s an edit with modifier indicator 1 (so you can override with a modifier when appropriate), and red means there’s an edit with modifier indicator 0 (so overriding is never an option). You also get the rule behind the CCI edit.

Under the edit warning, you’ll find the code’s lay term and, depending on your subscription, links to articles. Check the right-side column for RVUs and fees.

Any Questions?

You get other goodies with CCI Edits Checker, too, like the option to download your results and easy access to the Medicare NCCI Policy Manual for NCCI guidelines. What else would you like to know?

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Take a Peek at 2018 ICD-10-PCS Updates

Thu, Jun 1, 2017

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2018 updates

It’s only June of 2017, but for coders that means it’s time to start watching for 2018 updates. ICD-10-PCS files are already available for review. This inpatient coding system, which changes to the 2018 version on Oct. 1, 2017, will see 3,562 new codes and 646 deletions for a total of 78,705 codes in the next version. There will be 1,821 revisions, too. What’s changing? Here are some highlights.

Get Clued In to Code Set Changes

CMS helpfully offers an update summary. It pulls out three main changes to watch:

  • Revisions for clarity and usefulness in the Medical and Surgical section
  • Addition of endoscopic approaches to various tables
  • Guideline updates.

To view just the changes, download the Addendum from the CMS 2018 ICD-10-PCS and GEMs page.

Medical and Surgical: As you review the definitions addenda file, watch for deletions that have a related addition.

Example: For Section 0 (Medical and Surgical), Character 4 (Body Part), you’ll see “Delete” next to the ICD-10-PCS value Nose. But before you start wondering how you’ll report nose procedures, scroll down a bit to find the added value Nasal Mucosa and Soft Tissue. The terms in the definition for both values are the same.

Tables: The tables addenda file is more than 400 pages, so homing in on the changes specific to what you code will be important for manageable 2018 preparation.

Example: If you report procedures on the coronary arteries, check out the changes to the table for 3E0 with fourth character 7. You’ll see a new fifth character option 4 for Percutaneous Endoscopic.

Know What’s New for ICD-10-PCS Guidelines

The guideline changes you can expect to see came about in part from public comment. Something to keep in time next time you think of a suggestion!

Added: Totally Tubular New Guideline B4.1c

New guideline B4.1c (under B4, Body Part General Guidelines) clarifies coding procedures on tubular structures:

If a procedure is performed on a continuous section of a tubular body part, code the body part value corresponding to the furthest anatomical site from the point of entry.

Example: A procedure performed on a continuous section of artery from the femoral artery to the external iliac artery with the point of entry at the femoral artery is coded to the external iliac body part.

Revised: Completed Incomplete Procedure Guideline B3.3 

The wording for B3.3 will see some changes in the header and first sentence. The changes are in red:

Discontinued or incomplete procedures

If the intended procedure is discontinued or otherwise not completed, code the procedure to the root operation performed.

Revised: Root Operation Over Control Clarified in B3.7

Guideline B3.7 about Control will change the specified list of definitive root operations to a list of examples. The text involved in the changes is marked in red

2017: If an attempt to stop postprocedural or other acute bleeding is initially unsuccessful, and to stop the bleeding requires performing any of the definitive root operations Bypass, Detachment, Excision, Extraction, Reposition, Replacement, or Resection, then that root operation is coded instead of Control.

2018: If an attempt to stop postprocedural or other acute bleeding is initially unsuccessful, and to stop the bleeding requires performing a more definitive root operation, such as Bypass, Detachment, Excision, Extraction, Reposition, Replacement, or Resection, then the more definitive root operation is coded instead of Control.

Revised: Temporary Device at Center of B6.1a

Under Device General Guidelines, B6.1a will see an expansion, with the addition of all the red text

A device is coded only if a device remains after the procedure is completed. If no device remains, the device value No Device is coded. In limited root operations, the classification provides the qualifier values Temporary and Intraoperative, for specific procedures involving clinically significant devices, where the purpose of the device is to be utilized for a brief duration during the procedure or current inpatient stay.

How About You?

Have you reviewed the PCS files? What did you think of the changes?

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Get to Know Aftercare Z Codes: Official Guidelines and Examples

Tue, May 30, 2017

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doctor caring for patient

How many of the 15 pages on Z codes have you read in the ICD-10-CM Official Guidelines for Coding and Reporting? More than a page is devoted to aftercare visit codes in Section I.C.21.c.7. Here’s a quick refresher on what you should know about aftercare coding, including the ICD-10 twist for injury codes.

The Basic Rule: Apply Aftercare Codes for Recovery Phase

The Official Guidelines (OGs) tell you to look at Z42-Z51 for aftercare Z codes. The general rule is that you use these codes when the patient has had initial treatment and the patient needs care for recovery or for consequences of the disease. Put another way, the codes aren’t appropriate for use when the disease is current or acute.

Remember the Antineoplastic Exception

Category Z51 may be included in the list of aftercare codes, but oncology coders know that they have to use Z51.0 (Encounter for antineoplastic radiation therapy) or a code from Z51.1- (Encounter for antineoplastic chemotherapy and immunotherapy) as the first-listed diagnosis when the patient encounter is for radiation, chemotherapy, or immunotherapy to treat a neoplasm. That means these codes apply when the disease is still active and under treatment.

Example: Suppose a patient presents for an antineoplastic chemotherapy infusion to treat a malignant neoplasm of the descending colon. Your first-listed code will be Z51.11 (Encounter for antineoplastic chemotherapy) followed by neoplasm code C18.6 (Malignant neoplasm of descending colon).

Caution: Not every case involving a neoplasm falls under the exception. For instance, a patient who has undergone successful surgery to remove a brain neoplasm may present for wound evaluation and a neurological check. In that case, Z48.3 (Aftercare following surgery for neoplasm) may be appropriate.

Steer Clear When Coding Injuries

Another exception to the “when to use aftercare Z codes” rule involves coding for aftercare of injuries. Instead of using Z codes you should turn to ICD-10’s infamous seventh characters to report subsequent care of an injury.

Example: You report T22.232D (Burn of second degree of left upper arm, subsequent encounter).

Combine and Sequence Those Z Codes Correctly

Reporting a Z code as the first-listed diagnosis is usually appropriate. But there are times the aftercare code may be secondary.

Example: The OGs offer the case of a patient undergoing colostomy closure during an admission for another condition. In this instance, Z43.3 (Encounter for attention to colostomy) may be an additional code.

Using multiple aftercare codes on the same claim may be appropriate, too. Base sequencing on the circumstances of the encounter, and be sure to check the code’s instructions to confirm the specific guidelines you need to apply, the OGs state.

Watch for: Including both a status Z code and an aftercare Z code on the claim also may be the right move.

Do: You may report Z95.1 (Presence of aortocoronary bypass graft) with Z48.812 (Encounter for surgical aftercare following surgery on the circulatory system) to provide more detail about the surgery involved, the OGs state.

Don’t: When the aftercare code gives the status, don’t add a status code. For instance, the OGs say not to use Z43.0 (Encounter for attention to tracheostomy) with Z93.0 (Tracheostomy status).

What About You?

Which Z codes do you use? Do you review the OGs each year?

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MACRA’s Money Effects Depend on Providers, Study Finds

Fri, May 26, 2017

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MACRA and its shift to a value-based payment model has people in the business of healthcare talking. While most of us may be thinking about the MIPS (Merit-Based Incentive Payment System) track for the Quality Payment Program, there is another option: Alternative Payment Models (APMs). An APM offers incentive payments for high quality, cost-efficient care.

Will Physician or Hospital Payment See Bigger Changes?

A team from RAND Corporation looked into the effects of APMs by using the RAND Health Care Payment and Delivery Simulation Model (PADSIM), which provides a framework for seeing how providers act in response to payment policy changes.

Here are a couple of the key findings reported in the research brief:

  • Medicare spending on physician services will be lower under MACRA. The RAND team estimates a drop somewhere between $35 billion and $106 billion.
  • There’s a wide range of possibilities when it comes to hospital payment changes. They could see an increase of $32 billion or a decrease of $250 billion.

Whether payment incentives drive changes in physician behavior will be a major factor in which direction hospital payment goes. The RAND research brief lists the examples of “working to avoid hospital readmissions or reducing use of hospital care,” and also states that having well-designed APMs is an important factor in encouraging participation.

From a financial perspective, the research indicates healthcare business models will need an update to be based around value.

Where to Learn More About APMs

You can see a list of Advanced APMs on the CMS APM site. Examples include Comprehensive Primary Care Plus (CPC+), Next Generation ACO Model, and Oncology Care Model (OCM).

To get a better idea of what CMS wants to see in an APM model, check out the Alternative Payment Model Design Toolkit.

You have to submit the quality data your Advanced APM requires, but meeting participation requirements in 2017 brings a 5 percent incentive payment in 2019. The CMS site indicates you must receive a quarter of your Part B payments through the Advanced APM or see 20 percent of your Medicare patients through the Advanced APM.

What About You?

Will you be using the APM track? What have you learned?

 

 

 

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Here’s What’s in Store for Medicare Advantage and Part D in 2018

Tue, May 23, 2017

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Medicare Advantage and Part D

Check out these bullet points for highlights from the 2018 Medicare Advantage and Part D payment and policy updates posted by CMS.

Medicare Advantage

Medicare Advantage (MA) plans, sometimes called Medicare Part C, are private plans approved by Medicare for people enrolled in Medicare. Medicare pays a fixed amount to the MA plan company, and the company provides Medicare Part A (hospital) and Part B (medical) coverage. The plans often offer Part D (prescription drug) coverage, too.

  • The expected total change in revenue is 2.95 percent for Medicare Advantage. That’s 0.45 percent for the expected average change in revenue plus 2.5 percent for coding trends. That’s a bit above the 2.75 percent total listed in the Advance Notice. It’s also worth noting that actual amounts may vary.
  • Calculation of risk scores will use encounter data for 15 percent, and Risk Adjustment Processing System (RAPS) and Medicare Fee-for-Service (FFS) diagnoses for 85 percent. The 2018 Advance Notice had proposed to continue to use 75 percent RAPS and 25 percent encounter data, but comments played a part in deciding on the final 85/15 blend. In short, operational issues led to commenters suggesting either a more limited use of encounter data or an adjuster.

Part D

As mentioned above, Part D offers drug coverage.

  • Part D benefit parameters see some changes. For instance, the deductible for the standard benefit in 2017 is $400 and in 2018 it’s $405, and the out-of-pocket threshold will change from $4,950 to $5,000.
  • Opioid overutilization criteria change in 2018. CMS posted an analysis including these changes (bullets below are direct quotes):
    • Current Opioid Overutilization Criteria:
      • Use of opioids with cumulative daily MED [morphine equivalent dose] exceeding 120 mg for at least 90 consecutive days with more than 3 prescribers and more than 3 pharmacies contributing to their opioid claims, during the most recent 12 months, excluding beneficiaries with cancer diagnoses and beneficiaries in hospice.
    • Revised Opioid Overutilization Criteria:
      • During the most recent six months:
        • Use of opioids with an average daily MED equal to or exceeding 90 mg for any duration, and
        • Received opioids from more than 3 prescribers and more than 3 pharmacies, OR from more than 5 prescribers regardless of the number of dispensing pharmacies.
      • Beneficiaries with cancer diagnoses and beneficiaries in hospice are excluded.
      • Prescribers associated with a single TIN are counted as a single prescriber.

How About You?

What do you think of the 2018 plan?

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4 Motivators for Sticking to the Coding Straight and Narrow

Mon, May 8, 2017

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Compliant coding is worth the effort!

If you ever take the “throw everything out there and see what sticks” approach to coding, it’s time to rethink that strategy. Carefully choosing the wrong codes to bring in more money is no way to code either. Next time you need inspiration to steer clear of these methods, reach for these four reasons coding correctly really is worth the effort.

1. ‘Them’s the Rules’

Choose any code set or a payer, and it likely won’t take you long to find a rule saying that you must assign a code based on what the documentation supports and what the reporting guidelines require. Simply put, a big part of being good at our chosen profession is following the rules.

For instance, if you’re looking at a close-but-not-quite procedure code, remind yourself that the Introduction to the AMA CPT® manual states, “Do not select a CPT® code that merely approximates the service provided.”

And if you find yourself considering a questionable choice and thinking, “It’s not like I’m masterminding a $50 million healthcare fraud scheme,” take a pause. Reassess to ensure your coding complies with the rules. Your career and even your finances and freedom could depend on it.

2. Face Audits Stress-Free (OK, With Less Stress)

Putting in the effort to make each claim accurate will do a lot to boost your confidence if a payer chooses you for an audit. If your services are medically necessary, the documentation supports that, and the coding matches the documentation, an audit should go fairly smoothly. You’ll know that you haven’t done anything intentionally that could put you and your team at risk.

3. Your Future Self Will Thank You

When you submit clean claims, you reduce denials which is good for at least two reasons (in addition to the audit benefits above). One is that you won’t have to go through all the time and energy required for rework and appeals. Another is that you won’t risk losing money by letting denials slide.

It also doesn’t hurt that with every little bit of research you do for one claim, you’ll reap the benefits of that research when similar cases come up in the future.

4. Get the Nickname Captain Accuracy

Doing the hard work day in and day out does get noticed. You’ll help your career and future advancement opportunities by getting a reputation for understanding complex coding rules and payer requirements. Never forget how important you are to your organization’s financial health and compliance.

How About You?

Do you ever have those moments where you wonder if keeping up with coding rules is worth it? What do you do to power through? How do you make keeping up with rule changes easier?

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